Ann Thorac Surg 2002;74:941-942
© 2002 The Society of Thoracic Surgeons
How to do it
A technique to protect an axillo-coronary bypass graft
Harumasa Yasuda, MDa,
Nobuo Sakagoshi, MD*a
a Department of Cardiovascular Surgery, Kawachi General Hospital, Osaka, Japan
Accepted for publication April 1, 2002.
* Address reprint requests to Dr Sakagoshi, Kawachi General Hospital, 28 Yokomakurahigasgi, Higashiosaka, Osaka, Japan
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Abstract
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We describe a simple technique to protect an axillo-coronary bypass graft with a stretch, thin-walled 6-mm polytetrafluoroethylene graft with removable rings.
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Introduction
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Axillo-coronary bypass using reversed saphenous vein may be useful to revascularize coronary artery branches when the internal thoracic artery is not an adequate conduit [1–3]. However, the route of the graft into the thoracic cavity may limit its patency and the application of this procedure. As there is no natural passage to reenter the chest cavity, we devised a simple technique to protect the saphenous vein graft.
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Technique
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A 5-cm transverse incision is performed 2 cm below parallel to the clavicle just behind the sternochondral junction. The axillary artery is then exposed between the pectoralis major and deltoid muscles. A full midline sternotomy is made. After systemic heparinization the axillary artery is clamped and incised. A 4-mm punch is used to prepare a site on the axillary artery for proximal anastomosis. One end of the saphenous vein is sutured to the artery using 7-0 polypropylene and the graft is tunneled beneath the axillary vein. The left pleural cavity is opened and a wide hole in the intercostal space adjacent to the anastomosis is created digitally. A 6-mm expanded polytetrafluoroethylene (ePTFE) graft (WL Gore, Flagstaff, AZ) is placed in the tunnel to shield the saphenous vein graft. The covered vein graft is introduced into the chest cavity, then the ePTFE graft is trimmed. Care must be taken not to make a kink of the saphenous vein graft at the distal end of the ePTFE graft. The other end of the saphenous vein is anastomosed to the coronary artery (Fig 1).
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Fig 1. The saphenous vein graft covered with expanded polytetrafluoroethylene (ePTFE) graft is allowed into the thoracic cavity. The forceps points out the distal end of the ePTFE graft. A T graft is anastomosed to the left anterior descending artery and right coronary artery in this case.
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Comment
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It has been reported that the axillary artery can be used as the proximal anastomosis for reversed saphenous vein bypass of the coronary arteries. The procedure can be helpful when the internal thoracic artery has inadequate flow. Moreover when the ascending aorta is severely calcified or atherosclerotic the procedure can provide an optional source of graft inflow [1, 2]. The axillary artery has not been routinely used as a source of inflow to supply the coronary system. The reason is probably that there is no natural passage to reenter the chest cavity. The tunnel of the graft may limit its patency and the application of this procedure. Several routes have been reported such as a subcutaneous course [4], a tunnel through the bed of the second costal cartilage [5], and a tunnel through the intercostal muscle. Bonatti and colleagues [1] chose a tunnel through the intercostal muscle. Others have recommended partial rib resection and pointed out that neointimal hyperplasia might develop at the rib crossing site [6]. Tovar and associates [2] have not found rib resection necessary if the intercostal incision is wide enough to admit two fingers.
The route choice for the axillo-coronary bypass is controversial. We used ringed ePTFE graft to protect the saphenous vein graft. The ringed ePTFE is not collapsible under normal conditions and serves as a protective encasement in the tunnel to the thoracic cavity. Although the direct impact of ePTFE on the long-term patency of the saphenous vein graft is not yet known, we believe that the described technique is simple and allows for extended use of the axillary artery as a source of graft inflow.
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Acknowledgments
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The authors thank Dr Wade L. Knight for his assistance in language editing.
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References
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- Bonatti J., Hangler H., Antretter H., Muller L.C. Axillocoronary bypass for severely atherosclesotic aorta in coronary artery bypass grafting. J Thorac Cardiovasc Surg 1998;115:956-957.[Free Full Text]
- Tovar E.A., Blau N., Borsari A. Axillary artery-coronary artery bypass grafting. J Thorac Cardiovasc Surg 1998;115:242-243.[Free Full Text]
- Magovern J.A., Hunter T.J., Yoon P.D. Clinical result with left axillary to left anterior descending coronary bypass. Ann Thorac Surg 2001;71:561-564.[Abstract/Free Full Text]
- Bonatti J., Laudurner R., Hangler H., Katzgraber F. Anatomical studies concerning technical feasibility of minimally invasive axillocoronary bypass grafting. Eur J Cardiothorac Surg 1998;14(Suppl 1):570-574.
- Knight W.L., Baisden C.E., Reiter C.G. Minimally invasive axillary-coronary artery bypass. Ann Thorac Surg 1997;65:304-305.
- Tovar E.A., Bonatti J. The route choice for the axillocoronary bypass graft. J Thorac Cardiovasc Surg 1998;116:1086-1087.[Free Full Text]
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Abstract
Introduction
